37卷6期

• Link 政策論壇 Policy Forum
• 從治癒到照護－論加護病房病患的善終從治癒到照護－論加護病房病患的善終
• 張厚台、陳端容
  Hou-Tai Chang, Duan-Rung Chen
• 無
  none
• 無
  none
• 599 - 601
• 10.6288/TJPH.201812_37(6).PF03

• Link 綜論 Review Article
• 低價值醫療之探討A review of low-value care
• 吳潔人、吳怡玟、郭年真
  Chieh-Jen Wu, Yi-Wen Wu, Raymond N. Kuo
• 低價值醫療；醫療品質；以病人為中心；成本效益
  low-value care?;?quality of care?;?patient-centered?;?cost effectiveness
• 全球的衛生醫療保健支出逐年上漲，各國開始針對「無效率照護」、「過度使用醫療資源」等議題進行討論，因此「低價值醫療」（Low-value care）一詞逐漸備受重視。低價值醫療可能導致醫療費用上升、病人身體與心理傷害、壓縮高價值的醫療服務資源供給，更甚者可能造成醫源性傷害（Iatrogenic harm）的發生，因此若減少低價值醫療的利用，能減少不必要的治療與後續相關醫療費用支出。本研究整理低價值醫療議題的發展脈絡，接著釐清造成低價值醫療在「臨床人員」、「病患」以及「醫療體系」三個不同面向的因素，同時探討低價值醫療對於病患及醫院端的影響，最後整理出近年來各國低價值醫療利用現況、政策介入與改善情形，進一步探討台灣未來針對低價值醫療可以改善的方向與目標。
  The rising cost of health care has raised concerns about the provision of ”ineffective care,” ”inefficient care,” and ”unwanted care” in many countries. ”Low-value care” has received attention because it can increase the cost of health care, cause physical and mental harm to patients, including iatrogenic harm, and reduce the availability of high-value health care services. Efforts to reduce the prevalence of low-value care can, therefore, reduce the incidence of unnecessary treatments and their accompanying costs. This paper reviews the contexts in which low-value care occurs and investigates the manner in which clinicians, patients, and health care systems contribute to the prevalence of low-value care. This paper also discusses the effect of low-value care on patients and health care providers. Finally, we summarize the current status of policies and interventions aimed to curb the provision of low-value care in several countries to illuminate potential targets for policy interventions and solutions to reduce the provision of low-value care in Taiwan.
• 602 - 613
• 10.6288/TJPH.201812_37(6).107088

• Link 評論 Commentary
• 評論：低價值醫療之探討Commentary:A review of low-value care
• 李亞欣
  Ya-Hsin Li
• 無
  none
• 無
  none
• 614 - 614
• 10.6288/TJPH.201812_37(6).10708801

• Link 綜論 Review Article
• 台灣一般護理之家評鑑：十年回顧與展望Review and outlook of Taiwan nursing homes accreditation
• 梁亞文
  Yia-Wun Liang
• 一般護理之家 ； 評鑑
  nursing home ; accreditation
• 面對人口老化及家庭照顧支持功能的式微，一般護理之家扮演了重要的長照服務角色，且其照護品質日益受到重視。台灣一般護理之家評鑑始自2009年，為回應各界對一般護理之家評鑑制度的批評與建言，2017年衛生福利部配合國家政策推動評鑑改革，以回歸住民安全與照護照顧品質的精神，簡化一般護理之家評鑑基準及作業。迄今，一般護理之家評鑑實施屆滿十年，展望未來，本文透過檢視台灣一般護理之家評鑑發展歷程，並提出建言，作為後續評鑑制度修訂參考。
  Faced with an aging population and decline in family support functions, nursing homes are an increasingly essential component of long-term care in Taiwan. Furthermore, the demand for high-quality nursing home care is on the rise. Taiwan launched a nursing home accreditation program in 2009. Subsequently, in 2017, in response to criticism and suggestions from the public, the Ministry of Health and Welfare sought to reform the accreditation system for nursing homes by streamlining the system and standards in accordance with resident safety and care quality. At the time of this review, approximately one decade had passed since the implementation of the aforementioned nursing home accreditation program. This paper reviews the process of nursing home accreditation and provides recommendations for future reform.
• 615 - 625
• 10.6288/TJPH.201812_37(6).107084

• Link 原著 Original Article
• 長期追蹤研究台灣幼童飲食攝取與生長速度Dietary intake and growth rates of young children in Taiwan: a longitudinal study
• 陳韻伶、徐桂婷、盧立卿
  Yun-Ling Chen, Kuei-Ting Hsu, Li-Ching Lyu
• 幼童；生長速度；飲食攝取
  young children ; growth rate ; dietary intake
• 目標：本研究觀察台灣北中南地區幼童2至6歲期間的飲食變化、生長速度，並探討其食物類別及營養素攝取量與生長速度之相關性。方法：結合台灣北中南區2至6歲幼童長期追蹤之每年兩日24小時飲食回憶及體位等資料，分析2～6歲期間食物類別及營養素攝取量對於生長速度的影響。結果：台灣北中南區幼童飲食及生長速度並無地區差異，而3、4歲為幼童飲食變化的轉變點，熱量及多種營養素（蛋白質、脂質、醣類）來源逐漸以一般家庭飲食為主。分析食物類別（food groups）攝取與生長速度相關性，發現2～6歲期間植物油類（vegetable oils）攝取量與體重增加量（r=0.32, p＜0.05）及體重z分數增加量（r=0.27, p＜0.05）呈顯著正相關，肉類及水果類攝取量與身高增加量（r_肉=0.23, r_果=0.25, p＜0.05）及身高z分數增加量（r_肉=0.23, r_果=0.25, p＜0.05）呈顯著正相關。營養素（nutrients）分析則發現植物性脂質（plant fat）攝取量與體重增加量呈顯著正相關（r=0.22, p＜0.05），熱量（r=0.23, p＜0.05）、維生素B_6（r=0.24, p＜0.05）、膽鹼（r=0.25, p＜0.05）、鉀（r=0.22, p＜0.05）攝取量與身高增加量呈顯著正相關。結論：高營養密度食物可提供充足的微量營養素，有助於幼童身高之生長，而過多油脂攝取則會使體重增加。
  Objectives: To examine the dietary transition and growth rates of children aged 2 to 6 years from northern, central, and southern Taiwan and thereby determine the relationships between food groups, nutrient intake, and growth rate. Methods: This cohort study recruited participants from various areas of Taiwan. Food groups and nutrient intake data of children aged 2 to 6 years were analyzed through 2-day 24-hour dietary recall. Anthropometric data were converted to age-and sex-specific Z-scores to calculate growth rates. Results: No differences were observed in the dietary intakes and growth rates of young children from northern, central, and southern Taiwan. The turning point in the children's dietary patterns appeared at ages 3-4 years, because their energy and the majority of nutrients gradually began to be received from a normal diet. Analysis of food groups revealed that vegetable oils were significantly and positively correlated with weight gain (r = 0.32, p < 0.05) and weight-for-age Z-score gain (r = 0.27, p < 0.05); furthermore, meat and fruit intake were significantly and positively correlated with height gain (r_(meat) = 0.23, r_(fruit) = 0.25, p < 0.05) and height-for-age Z-score (HAZ) gain (r_(meat) = 0.23, r_(fruit) = 0.25, p < 0.05). In addition, weight gain was significantly and positively correlated with the intake of plant fat (r = 0.22, p < 0.05); height gain was significantly and positively correlated with the intake of energy (r = 0.23, p < 0.05), vitamin B_6 (r = 0.24, p < 0.05), choline (r = 0.25, p < 0.05), and potassium (r = 0.22, p < 0.05); however, only energy (r = 0.22, p < 0.05) and choline (r = 0.22, p < 0.05) had the same trends as HAZ gain. Conclusions: High nutrient-dense foods could provide young children with sufficient micronutrients to help with height growth, whereas excessive fat and oil intakes may cause weight gain.
• 626 - 637
• 10.6288/TJPH.201812_37(6).107090

• Link 原著 Original Article
• 護理之家實施安寧療護服務措施之研究Service measures of hospice care in nursing homes in Taiwan
• 龍紀萱、李依臻
  Chi-Hsuan Lung, I-Jhen Lee
• 護理之家 ； 安寧療護 ； 服務措施
  nursing home ; hospice care ; care measures
• 目標：目前國內護理之家面對疾病末期與瀕死階段住民提供之相關服務，尚有待進一步探討。本研究目的企圖建構護理之家安寧療護之服務措施，以供相關單位、機構與實務專業人員參考。方法：依地理區域於全國舉辦四場次焦點團體會議，參加對象為立案且經衛生福利部評鑑為甲等（含）以上護理之家的實務工作者，共計34人參與。結果：建構護理之家安寧療護服務措施包含三個面向與十二個措施：（一）解決人力資源不足：建立機構內的照護團隊、完善的教育訓練、機構間之跨團隊合作、提升對安寧的認知；（二）建立良好制度：解決死診開立問題、簽署DNR措施、結合相關政策、設立安寧療護專區；（三）面對死亡的藝術：安寧接案考量、促進有效溝通、全人照護面向、往生後事與悲傷輔導。結論：應先了解推行安寧療護服務措施面臨的困境，再者評估現有的資源，從人力資源與制度建立進行改善。最後，建議從政策面、機構面與人員面解決所面臨的困境，以利安寧療護實施於護理之家。
  Objectives: In Taiwan, the services currently available for terminally ill nursing home residents require further discussion. This study established service measures of hospice care in nursing homes for the reference of related units, facilities, and practicing professionals. Methods: Four focus group meetings were convened in Taiwan according to geographic location. Thirty-four practicing professionals from registered nursing homes with accreditation of A or higher by the Ministry of Health and Welfare attended the meetings. Results: The establishment of service measures of hospice care in nursing homes comprised 3 aspects, with a total of 12 measures: (1) resolving labor shortages (establishing caregiving teams within the facility, providing comprehensive education and training, and promoting interfacility teamwork and hospice care knowledge), (2) establishing an appropriate system (resolving problems concerning the issuing of death certificates and DNR promotion, incorporating related policies, and establishing designated areas for hospice care), and (3) confronting death (considering hospice admission, facilitating effective communication, implementing holistic health care, assisting in funeral affairs, and providing grief counseling). Conclusions: To facilitate the implementation of service measures for hospice care in nursing homes, the procedure should be started by considering the difficulties associated with implementation, followed by the evaluation of current resources, improvement of the system and human resources situation, and finally, addressing of the dilemma faced by the relevant policymakers, organizations, and personnel.
• 638 - 650
• 10.6288/TJPH.201812_37(6).107093

• Link 原著 Original Article
• 醫院策略與急性心肌梗塞照護品質之關係Association of hospital strategies with quality of care for acute myocardial infarction
• 廖思詠、游宗憲、董鈺琪
  Szu-Yung Liao, Tsung-Hsien Yu, Yu-Chi Tung
• 急性心肌梗塞 ； 醫院策略 ； 照護品質
  acute myocardial infarction ; hospital strategies ; quality of care
• 目標：台灣醫院近年持續改善急性心肌梗塞（acute myocardial infarction, AMI）的照護品質，不過未有研究探討那些醫院策略與AMI照護品質有關，本研究目的係探討醫院策略與AMI照護品質的相關性。方法：本研究為橫斷性研究，以收治全台灣大部分AMI住院病人之96家醫院，以郵寄問卷方式進行普查，測量醫院2015年至2016年醫院策略實施的情況，問卷回收率為73.96%，再與中央健康保險署全民健康保險AMI照護品質資訊公開之照護品質指標資料合併，採用複線性迴歸模式，在控制醫院特性與病人特性後，探討醫院策略與AMI照護品質（血脂低密度脂蛋白檢查、阿斯匹靈、腺嘌呤二磷酸接受體拮抗劑、乙型阻斷劑及血管收縮素轉化?抑制劑或血管收縮素接受體阻斷劑使用率）之相關性。結果：醫院所推行的三項策略與較高AMI藥品治療使用率有關。結論：隨時（含假日及夜間）有心臟專科醫師於醫院輪值處置病人、監測出院病人7或14日回診之百分比、臨床人員與緊急醫療救護人員定期開會與較佳的AMI照護品質有關。
  Objectives: In recent years in Taiwan, hospitals have continuously improved quality of care for acute myocardial infarction (AMI). However, no study has examined which hospital strategies are associated with quality of care for AMI. This study investigated the association of hospital strategies with quality of care for AMI. Methods: This cross-sectional study was conducted in hospitals in which most patients with AMI throughout Taiwan are admitted. A structured questionnaire was developed and mailed to 96 hospitals to examine the implementation of hospital strategies between 2015 and 2016. The response rate was 73.96%. The data of quality measures for AMI care were obtained from the report titled ”Public Reporting for Quality of Care for AMI,” which is provided by the National Health Insurance Administration. Multivariate linear regression models were used to examine the association of the implementation of hospital strategies with AMI quality of care measures (rate of low-density lipoprotein cholesterol testing and rates of aspirin, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, adenosine diphosphate receptor inhibitor, and beta-blocker use). Results: Three hospital strategies were found to be associated with high rates of AMI medication use. Conclusions: Having cardiologists always on site, monitoring percentages of 7- or 14-day outpatient follow-up, and holding regular meetings between hospital clinicians and emergency medical service providers are associated with better quality of care for AMI.
• 651 - 663
• 10.6288/TJPH.201812_37(6).107056

• Link 原著 Original Article
• 失智症與非失智症長者之照顧者醫療服務利用之比較Comparison of healthcare utilization between caregivers of dementia and nondementia older adults
• 詹書媛、游曉微、楊銘欽、李玉春、 陳雅美
  Su-Yuan Chan, Hsiao-Wei Yu, Ming-Ching Yang, Yue-Chune Lee, Ya-Mei Chen
• 失智症照顧者；醫療服務利用；長期照顧十年計畫；健保資料庫
  ?dementia caregivers?;?healthcare utilization?;?Ten-year Long Term Care Project (TLTCP)?;?Taiwan National Health Insurance
• 目標：比較台灣長期照顧十年計畫使用者中，失智症與非失智症照顧者醫療服務利用與費用。方法：本研究串聯照顧服務管理資訊平台與衛生福利資料科學中心資料庫，分析2008至2013年間，10,771位長照十年計畫使用者的照顧者，透過多變項羅吉斯迴歸與多變項線性迴歸，比較失智症與非失智症照顧者，在初次核定長照服務後一年內的門診、急診、住院利用與費用。結果：整體而言，失智症與非失智症照顧者在門診、急診、住院與整體醫療利用與費用皆未達統計顯著差異。然而，當被照顧者輕度失能時，失智症較非失智症照顧者每次急診費用高20.6%（p ＜ 0.01）、累積急診費用高31.9%（p ＜ 0.01）；被照顧者重度失能時，失智症較非失智症照顧者的住院使用次數多0.22次（p ＜ 0.05）。結論：失智症與非失智症照顧者的短期醫療利用無明顯差異，但失智症照顧者，特別是輕度失智症照顧者，可能更忽略自身健康、拖延就醫，最終尋求急性醫療資源協助。建議政策提供更多喘息服務，給予失智症照顧者時間滿足初級醫療服務需求。
  Objectives: To compare the healthcare utilization and expenditures between the caregivers of elderly adults with or without dementia who were in Ten-year Long Term Care Project (TLTCP) in Taiwan. Methods: Data were extracted from the population-based datasets of the Long-Term Care Service Management System and the National Health Insurance in Taiwan. 10,771 individuals who were the caregivers of elderly adults aged ?65 years in the TLTCP during 2008-2013 were included. Multiple logistic regression and multiple linear regression were used to compare the 1-year healthcare utilization and expenditures between the caregivers of elderly adults with or without dementia, including outpatients, emergency departments (EDs), and hospitalizations, after their care recipients being first time prescribed with LTC services. Results: In general, no significant differences were observed between the two groups. However, caregivers who cared for patients with dementia with mild disabilities had significantly 20.6% higher per ED fees (p < 0.01) and 31.9% higher ED fees (p < 0.01). Caregivers who cared for patients with dementia with severe disabilities had significantly 0.22 higher hospitalization visits (p < 0.05). Conclusions: In general, there is no difference in the use of healthcare services between the caregivers of elderly adults with or without dementia. Nevertheless, dementia caregivers, especially those caring for patients with mild dementia, are more likely to neglect their own health and hence tend to use more acute care healthcare resources. These results suggest policymakers to provide additional respite care services to allow caregivers time to seek for primary healthcare resources.
• 664 - 675
• 10.6288/TJPH.201812_37(6).107074

• Link 原著 Original Article
• 高齡者低握力評估的切點分析：台灣南部複合式健檢的實證分析Comparisons of cutoff points of poor grip strength for elderly people in southern Taiwan
• 秦秀蘭、林裕珍、蕭玉芬、莊華盈、李瑋
  Hsiu-Lan Chin, Yu-Chen Lin, Yu-Fen Hsiao, Hua-Ying Chuang, Wei Lee
• 切點 ； 肌力強度不足 ； 低握力 ； 衰弱症 ； 虛弱
  cut-off point ; low muscle strength ; poor grip strength ; frailty syndrome ; weakness
• 目標：本研究以台灣南部某農業縣2017年複合式健檢高齡民眾的握力檢測資料進行分析，透過低握力評估切點分析，了解受試者虛弱的情形。方法：受試者為男性999人（73.69±6.39歲）、女性1,212人（72.76±6.04歲）。以電子握力測試儀進行施測；以SPSS 20.0統計軟體進行分析。結果：男女受試者百分位數20的握力值與AWGS的評估切點相近；以受試者性別和BMI進行調整的分析，男性低握力比例為5.79%-71.43%，女性為9.55%-63.64%。FNIHSP評估切點的分析，男性低握力比例為10.88%-47.76%，女性為4.69%-31.37%。AWGS評估切點的分析則顯示男性低握力比例為10.88%-47.76%，女性為12.24%-45.10%。結論：三種切點的低握力評估結果，男女的低握力比普遍隨著年齡增加而遞增。其中，FNIHSP評估切點的分析，三個年齡層男性低握力比例大約都是女性的1.5倍，可見FNIHSP的評估切點並不適用於國內高齡者。以男女BMI調整的評估切點分析，不僅低握力比與國內男女高齡者的衰弱盛行率研究相近，也反映不同身體質量對個體衰弱的影響。至於AWGS所設定的女性評估切點對我國女性高齡而言，相對較高，建議進一步依年齡進行調整。此外，本次男性參與者握力相對較低，受試者間差異較大；因此，呼籲男性高齡者的衰弱情形需要更多的關注。
  Objectives: The objectives of this study were to compare the cutoff points of poor grip strength defined by Fried, EWGSOP, FNIHSP, and IWGS by subjecting community-dwelling elderly people in Southern Taiwan to a comprehensive physical examination. Methods: Participants comprised 999 men (age: 73.69±6.39 years) and 1,212 women (age: 72.76±6.04 years). Handgrip strength was measured using digital dynamometers (TKK 5101). Results: The 20th percentile of both men and women concurred with AWGS criteria. According to the Fried frailty criteria by adjustment for BMI, the prevalence of poor grip strength ranged from 5.79% to 71.43% among men and from 9.55% to 63.64% among women. According to FNIHSP criteria, the prevalence of poor grip strength ranged from 10.88% to 47.76% among men and from 4.69% to 31.37% among women. According to IWGS criteria, the prevalence of poor grip strength ranged from 10.88% to 47.76% among men and from 12.24% to 45.10% among women. Conclusions: The prevalence of poor grip strength increased with age in both sexes. According to the FNIHSP criteria, the prevalence of poor grip strength of older men was almost 1.5 times that of women, indicating the unsuitability of the cutoff points for Asians older than 65 years. The prevalence of poor grip strength based on Fried frailty criteria by adjustment for BMI not only corresponded with that from previous research on frailty in Taiwan but also revealed the effect of BMI on aging. Based on the AWGS criteria, the cutoff point of poor grip strength for older women was higher than those in other local studies in Taiwan. Therefore, this study suggests that the age factor be considered in the cutoff point of the AWGS. Moreover, attention should be paid to the weaker performance and greater individual differences in grip strength among the male participants.
• 676 - 685
• 10.6288/TJPH.201812_37(6).107061

• Link 實務 Public Health Practice
• 細懸浮微粒（PM_(2.5)）自2006年到2016年在台灣的時空趨勢Spatiotemporal trend of fine particulate matter 2.5 µm in Taiwan from 2006-2016
• 鄭永鴻、吳佩儒、 鄭意儒、莫之欣、藍郁青、 謝顯堂、 蔡善璞、陳昭文、溫啟邦、宋鴻樟
  Yung-Hung Cheng, Pei-Ju Wu, I-Ju Cheng, Chih-Hsin Mou, Yu-Ching Lan, Dennis P. H. Hsieh, Shan-Pou Tsai, Chao-Wen Chen, Chi-Pang Wen, Fung-Chang Sung
• 細懸浮微粒；歷年趨勢；工業站；一般站
  ?PM_(2.5)?;?annual trend?;?industrial station?;?non-industrial station
• 目標：空氣污染在最近再受到重視，尤其是細懸浮微粒（PM_(2.5)）及其發生源格外引起關切。本研究利用行政院環境保護署自2006年到2016年的監測資料比較工業測站和非工業測站歷年的PM_(2.5)變化趨勢。方法：我們自行政院環境保護署網站下載歷年各空品測站之逐小時監測資料，選擇有工業測站的苗栗、彰化、雲林和高雄地區，計算各類型測站PM_(2.5)的平均濃度，觀察每三年的變化，和繪成編年趨勢，比較工業測站和非工業測站測定值的差別，我們也分別繪製2016年各地各測站合計的月平均測值，觀察季節變化。結果：這四個地區，各測站的PM_(2.5)平均值均逐年下降（p≦0.001）。測定最大值最小值的差異大，可達100倍。在苗栗地區，頭份工業測站的監測數值由29.6 mg/m^3下降到18.2 mg/m^3，和非工業測站的數值相當。雲林和彰化工業測站的平均值則比非工業測站平均值較低。高雄地區有12個測站，工業測站的平均PM_(2.5)較其他類型測站平均值在前幾年較高，到2016年則下降較速，稍低於所有非工業測站的平均值。分析2016年四地區逐月平均值顯示，各地的PM_(2.5)夏季月份平均值遠低於冬、春月份的平均值。結論：各空品測站的PM_(2.5)逐年下降，工業區的PM_(2.5)排放未必高於交通排放或一般測站的測定值，下降幅度相當，期盼持續下降達到15 μg/m^3的標準或以下。
  Objectives: Air pollution has recently received renewed attention, particularly on the fine particulate matter of 2.5 µm (PM_(2.5)) and on sources that generate the pollutant. This study used the air pollution data monitored by the Environmental Protection Administration (EPA) of Executive Yuan to calculate the temporal trends of PM_(2.5) monitored from 2006-2016 and to compare levels between industry stations and non-industry stations. Methods: We obtained the EPA data and selected MiaoLi, Changhua, Yunlin and Kaohsiung areas to calculate mean PM_(2.5) levels over three 3-year and one 2-year time spans from 2006-2016, and plotted annual mean values for the same period. The temporal trends were compared between industry stations and non-industry stations for each area. Monthly means of all stations in each area in 2016 were also reported to observe the seasonal variations for the 4 areas. Results: The temporal trends of mean PM_(2.5) levels declined among all types of monitoring station with the maximum level could be up to 100-fold higher than the minimum level. At an industrial monitoring station of the MiaoLi area, the mean PM_(2.5) declined from 29.6 mg/m^3 in 2006 to 18.2 mg/m^3 in 2016, which were approximately similar to the corresponding mean levels estimated at two non-industry stations. The mean levels monitored at industrial stations were lower than that at non-industry stations in Changhua and Yunlin areas. Among 12 monitoring stations in the Kaohsiung area, the annual mean PM_(2.5) levels were greater at the industrial station than the respective means at 11 non-industrial stations, but declined rapidly to a slightly lower level in 2016. Monthly mean levels in 2016 showed that the PM_(2.5) levels were lower in summer months than in spring and winter months in all 4 areas. Conclusions: The PM_(2.5) levels were in declining trend in all areas in Taiwan. The effective mitigation of PM_(2.5) in industrial areas is comparable to that in non-industrial areas. We can probably expect to see it will soon reduce to the standard of 15 µg/m^3 or lower.
• 686 - 695
• 10.6288/TJPH.201812_37(6).107101